Opening MDs' Notes to Patients Wins Support

by David Pittman David Pittman,Washington Correspondent, MedPage Today
October 13, 2012

WASHINGTON -- Patients who viewed their doctors' notes reported feeling more in control of their care and practiced better medication adherence, a study showed.

Of the 5,391 patients who completed a post-intervention survey, between 77% and 87% said it made them feel more in control of their care, Tom Delbanco, MD, founding chief of the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston, and colleagues wrote in the Oct. 2 issue of Annals of Internal Medicine.

Medication adherence increased from 60% to 78%, they reported. But between 1% and 8% reported the notes caused confusion, worry, or offense, the survey found.

In all, 105 primary care providers at practices affiliated with hospitals in Boston, Seattle, and Danville, Pa., provided patients with electronic links to their doctors' notes. Physicians who shared their notes with patients through a secure Internet portal reported little or no additional volume in patient e-mails, time addressing questions, or longer office visits.

Few of the doctors surveyed at the end of the year-long study reported longer patient visits (0% and 5%) or needing more time addressing patient questions (0% to 8%), the survey found.

And seeing these results as a participating hospital, Beth Israel Deaconess Medical Center in Boston is making doctors' notes available throughout, it announced Thursday.

"This is the right thing to do," Kevin Tabb, MD, the hospital's CEO, said during a public meeting here. The hospital can separate itself in its crowded market by providing the service to patients, Tabb said.

The move was agreed upon by all department chairs. "I don't think anything we've done has been unanimously supported," Tabb said.

The Annals was hesitant to support Delbanco's study at first because results were purely observational and not looking at outcomes, editor Christine Laine, MD, said. But after seeing the results, the journal was compelled to publish the study and provided the first accompanying editorial written by the study's lead author.

Patients are already granted rights to their medical records through the Health Insurance Portability and Accountability Act, but rarely ask for them. Physicians also rarely share their notes without patients asking.

"The concept of open notes requires culture change, and that, no doubt, takes time," Delbanco said.

Physicians may be concerned about privacy breaches and workload issues with the open notes concept. But those concerns haven't come to fruition, users said.

"Physicians tend to overrate the risk and underrate the benefits," said Steven Stack, MD, emergency physician in Lexington, Ky., and chair of the American Medical Association's Board of Trustees.

Naturally, physicians are concerned with the philosophy initially. "They become more comfortable with it" as time goes on, Laine told MedPage Today.

Physicians are more apt to write an explanation of their findings knowing patients may read it and, if anything, write clearer notes.

But further study is needed on how exactly physicians change their habits because of note sharing, supporters said.

Some large and notable medical centers have already taken note of the philosophy and implemented it.

The University of Texas MD Anderson Cancer Center in Houston has had open notes since 2009. Tom Feeley, MD, head of the center's anesthesiology and critical care division, called it "one of the cheapest IT [information technology] projects they did."

He echoed the sentiment of others: the concept is welcome to patients and physicians alike after some initial apprehension.

The Department of Veterans Affairs with its robust electronic health record system is operating a pilot project to expose patients to their records. "You're going to see a lot more of this in the future," Delbanco told MedPage Today. "We're just starting."

In the area of lab data, states have varying laws on the release of lab results. Two states currently have legislation pending that would permit labs to release results directly to patients, Richard Schwabacher, general manager for mobile health platforms at Quest Diagnostics, told MedPage Today in an email.

The notes project, published in the Annals of Internal Medicine," is funded by the Robert Wood Johnson Foundation, the Drane Family Fund, the Richard and Florence Koplow Charitable Foundation, and the National Cancer Institute.